IPP Form

OMB No. 0930-0285

Expiration Date 03/30/2028

RESULT FORM

CMHS Infrastructure, Prevention, and Mental Health Promotion Indicators

GRANT ID (GRANT/COOPERATIVE AGREEMENT NUMBER) |____|____|____|____|____|____|____|____|____|____|

INSTRUCTIONS: Use one form per result. A result name must be unique in a given FFY quarter. The same result name can only be used in future quarters. If applicable, enter, enter the number and/or percent. Data must be entered electronically in the SPARS systems (https://spars.samhsa.gov). All results that occur within a quarter must be entered within 30 days of the end of that quarter. For example, if the quarter ends March 31, the data must be entered by April 30.

Indicator number and name (e.g., R1 – The number of individuals referred to mental health or related services): __________________________________________________________________

Is this a new result name? YES NO

Result Name: _________________________________________________________________

Date range of completion*: __________________________________________________

Result description: ___________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Number: ______________

Numerator (A4, NAB1, and AC1 only): ____________________________________________

Denominator (A4, NAB1, and AC1 only): __________________________________________

*Enter one of the following for the data range of completion: Quarter 1 = October 1 to December 31; Quarter 2 = January 1 to March 31; Quarter 3 = April 1 to June 30; Quarter 4 = July 1 – September 30

Public reporting burden for this collection of information is estimated to average 8 hours per quarter. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0285.